AUDIOLOGY CASE HISTORY FORM

PERSONAL INFORMATION
□Mr □Mrs □Ms □Dr
Last Name (If Child) Parent's First Name
First Name (If Child) Parent's Last Name

Date of Birth Date of Consultation

(D/M/Y) (D/M/Y)
Address Phone (H)
(W)
Emergency Contact
Name:
Occupation Phone:
Referred by

Reason for today's visit Referring Physician

Address
Telephone Number

HEARING, BALANCE & HEALTH HISTORY

Section 1. The following questions refer to ear blockage, fullness, pain, sensitivity,
ear sound and/or hearing difficulty experienced.

Do you currently experience (or have in the past) ear blockage, fullness, pain, sensitivity to
sound, ear sound (tinnitus) and/or hearing difficulty? □ Yes □ No □ Unsure

> If No: Please skip this section and go to section 2

> If Yes: In which ear? □ Right Ear □ Left Ear □ Both

For how long?

Do you have ear and/or head noise/tinnitus? □ Yes □ No □ Unsure

> If Yes: In which ear? □ Right Ear □ Left Ear □ Both
For how long?
Please describe the Noise

Do you have ear blockage, fullness, pain or sensitivity to sound? □ Yes □ No

> If Yes: In which ear? □ Right Ear □ Left Ear □ Both
For how long?

Have you ever had an ear infection or ear surgery? □ Yes □ No

> If Yes: In which ear? □ Right Ear □ Left Ear □ Both
Describe Treatment/Surgery
1200 Bay Street Suite 404 Toronto Ontario M5R 2A5 Tel (416) 967-7226 Fax (416) 967-4230

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Do you have hearing loss in your family? □ Yes □ No
> If Yes: Which family member?

Please select one circumstance that you may have experienced shortly before the first time you
had ear blockage, fullness, pain, sensitivity to sound, ear sound and/or hearing difficulty:
□ forcefully coughed/sneezed, flying, diving
□ had flu, cold, allergies
□ exposed to irritating fumes, paints and/or loud music or noise
□ dental surgery/work, TMJ disorders & bruxism (i.e., grinding teeth)
□ head trauma and injury (i.e., sport or motor vehicle accidents)
□ chiropractic adjustments due to stiff neck
□ intense period of stress at work or in personal life

Are (were) you regularly exposed to loud noise or music? □ Yes □ No

> If Yes: Is it? □ Work Related □ Recreational
> If Work Related, For how many years?
Do (did) you wear ear protection?
> If Recreational, What is (was) it from? □ Musical Instrument □ iPod/MP3

Are (were) you regularly exposed to heavy metal and/or organic solvents? □ Yes □ No
> If Yes: Is it? □ Work Related □ Recreational
> If Work Related, For how many years?
> If Recreational, What is (was) it from?

Section 2. The following questions refer to sensation(s)/symptom(s) of imbalance,

disequilibrium, dizziness or vertigo experienced.
Have you experienced imbalance, disequilibrium, dizziness or vertigo? □ Yes □ No

> If No, please skip this section and go to section 3.

> If Yes, please select the one that best describes the sensation or symptom experienced:
□ Sensation that room or surrounding is spinning around you
when your body is at rest (lying or sitting position)
□ Vague feeling of being off balance, unsteady, head discomfort
□ Feeling woozy, giddy, light-headed or/and that you are
going to faint or black out
□ Feeling of imbalance & disequilibrium when standing & walking
without dizziness
□ Difficulty walking straight, staggering gait (like you are drunk)
involuntarily bumping into things

1200 Bay Street Suite 404 Toronto Ontario M5R 2A5 Tel (416) 967-7226 Fax (416) 967-4230

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Please select the one that best describes the duration of the sensation/symptom described above:
□ less than 1 minute
□ more than 1 minute
□ hour(s)
□ day(s)

When did you first experience this sensation/symptom? Please describe in you own word:

How many episode(s) of the sensation described above have you had so far?

Was the most recent episode as strong in intensity and distress as the first one experienced?
□ Yes □ No

Please select the one situation that seems to trigger or bring about the sensation described above?
□ Change in head position (while rolling in bed, getting out of
bed, quickly looking up or bending forward)
□ During head extension while standing on a wobbling ladder or
while looking up at moving clouds
□ When eyes are closed or while walking in the dark
□ While standing up especially after long period of sitting
□ When overwork or during intense period of stress, anxiety, distress
□ With some medications, foods, drinks and recreational drugs

Please select all other symptoms that accompanied the sensation described above?
□ Ear and/or head noise (hissing, buzzing, blowing)
□ Hearing difficulty, distorted hearing, (things sound tinny)
□ Ear blockage, ear fullness, earache
□ Nausea, feeling hangover or seasick, vomiting, fatigued
□ Visual problems (blurred vision, double vision, eyes jerking)
□ Distress, sweating, trembling, shortness of breath, palpitations
□ Headache, migraines, nausea, visual disturbances
□ Convulsions, seizures
□ Slurred speech, confusion, numbness, tingling around mouth
□ Lack of body coordination (arms and legs)

Please select one circumstance that you may have experienced shortly before the first time you
had the sensation of imbalance, disequilibrium, dizziness and/or vertigo:
□ coughed/sneezed, flying, diving
□ got new glasses
□ exposed to irritating fumes, paints
□ had flu, cold, allergies
□ hadn't eaten in a long period of time
□ head trauma and injury (sport or motor vehicle accidents)
□ intense period of stress at work or in personal life
1200 Bay Street Suite 404 Toronto Ontario M5R 2A5 Tel (416) 967-7226 Fax (416) 967-4230

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3) The following questions refer to your general health status.

Do you suffer or have you been diagnosed with any of the following medical conditions
(please select all that apply)

□ Chronic Ear Infection □ Ménière’s Disease □ Otosclerosis □ Autoimmune Disorders

□ High/Low Blood Pressure □ Heart Diseases □ Artherosclerosis □ Respiratory Problems
□ Liver Diseases □ Kidney Diseases □ G.I. Track Problems □ Arthritis/Rheumatoid
□ Parkinson’s Disease □ Alzheimer’s Disease □ Stroke/Aneurysm □ Multiple Sclerosis
□ Anemia/Blood Diseases □ Iron Deficiency □ Diabetes □ High Cholesterol
□ Anxiety/Panic Attack □ Depression □ Migraines □ Eye/Vision Problems
□ Cancer Treatments:
□ Genetic Disorders:
□ Neurological Disorders:
□ Endocrine Disorders:
□ Head Trauma/Injury:
□ Others:

Are you on any prescription drugs for the above medical conditions? □ Yes □ No
> If Yes: Please list

Are you a smoker? □ Yes □ No

> If Yes: How many a day? _______________

Do you daily take St. John’s Wort and/or Gingko Biloba? □ Yes □ No

1200 Bay Street Suite 404 Toronto Ontario M5R 2A5 Tel (416) 967-7226 Fax (416) 967-4230

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CONSENT FOR PAYMENT

I acknowledge that Audiological Services are no longer covered by OHIP and all treatments are to be
paid by myself excluding individuals receiving financial assistance with Department of Veterans
Affairs, Ontario Disabilities Program, Ontario Works & Workplace Safety & Insurance Board
(formerly know as Workers Board Compensation). A list for the costs of services is available at the
reception desk.

I understand that payment will be due upon receipt of goods or services, or as agreed upon by the office
and me. Cash, Personal Cheques, Visa and Master Cards are recognized as forms of payment.

If coverage applies please provide identification number

□ Department of Veterans Affairs
□ Ontario Disability Program
□ Ontario Works
□ Worker's Board Compensation

CONSENT FOR TREATMENT

I understand that my hearing and balance health care will be provided by or under the direct
supervision of an Audiologist who is a registered member of the College of audiologists and Speech
Language Pathologists of Ontario (CASLPO), and who must comply with the regulations and
professional guidelines of this governing body.

CONSENT FOR PERSONAL INFORMATION

I have read and understood the privacy policy statement provided by the Audiology Clinic (can be
found at front reception) that outlines how my personal information will be collected, used, disclosed
and protected. I understand my right to review this personal information, which will be used to provide
me with hearing services. In some instances I may ask for specific information not to be collected.

I hereby give my consent for the following, concerning the care of:
(If Patient is a minor)

• Provision of hearing and balance health care by or under the direct supervision of an Audiologists
registered with CASLPO
• The collection, use and disclosure of personal information (see privacy statement)
• The release of my audiological report to the referral source (primary care physician)

SIGNATURE: DATE:

1200 Bay Street Suite 404 Toronto Ontario M5R 2A5 Tel (416) 967-7226 Fax (416) 967-4230